Functional Improvement after One- and

Two-Eye Cataract Surgery in the Salisbury

Eye Evaluation
Bryan S. Lee, MD, JD,1 Beatriz E. Munoz, MSc,1 Sheila K. West, PhD,1 Emily W. Gower, PhD1,2,3
Purpose: To determine the impact that cataract and cataract surgery have on clinical measurements of
vision, reading speed, objective mobility performance, and subjective visual functioning.
Design: Prospective, population-based study.
Participants: A total of 1739 Salisbury Eye Evaluation (SEE) participants without previous cataract surgery
with bilateral baseline best-corrected visual acuity (BCVA) of logarithm of the minimum angle of resolution
(logMAR) 0.3 (20/40) or cataract surgery between rounds 1 and 2.
Methods: Participants were categorized on the basis of cataract surgery by round 2 into no surgery,
unilateral surgery, or bilateral surgery. Visual performance, mobility-based tasks, and the Activities of Daily Vision
Scale (ADVS) were measured at baseline and 2 years. Mobility score was converted into a z score by subtracting
the participants time from the population baseline average and then dividing by the standard deviation.
Comparisons were made between the no surgery and surgery groups using multivariate linear regression.
Main Outcome Measures: Change in bilateral BCVA in logMAR, contrast sensitivity, reading speed in words
per minute (wpm), mobility score, and ADVS.
Results: During the study period, 29 participants had cataract surgery on both eyes, 90 participants had
unilateral surgery, and 1620 participants had no surgery. After adjusting for baseline value, demographics,
depression, and mental status, the unilateral surgery groups BCVA improved 0.04 logMAR (P 0.001) and the
bilateral groups BCVA improved 0.13 compared with no surgery (P0.001). Overall mobility declined in all
groups. The unilateral groups z score decreased 0.18 more than that of the no surgery group (P 0.02), whereas
the bilateral group showed a 0.18 z score improvement compared with no surgery (P 0.19). Change in reading
speed significantly improved in the unilateral and bilateral groups compared with no surgery (12 and 31 wpm,
respectively). The bilateral surgery group showed significant positive change in ADVS compared with no surgery
(5 points of relative improvement; P 0.01), whereas the unilateral group showed a 5-point relative decline
(P0.001).
Conclusions: Cataract negatively affects both subjective quality of life and objective performance measures.
Unilateral cataract surgery improves visual functioning, but the largest gains are found in patients who undergo
second-eye cataract surgery. This finding supports second-eye cataract surgery for patients with visual or
functional symptoms even after successful first-eye surgery.
Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed
in this article. Ophthalmology 2013;120:949 955 2013 by the American Academy of Ophthalmology.

Vision impairment has been shown to increase physical

disability and decrease mobility and even has been correlated with increased mortality.1,2 It also has been associated
with decreased physical and mental health on the generic
36-item Short Form quality of life measure.3 Cataract, the
most common cause of vision impairment among the elderly, affects more than 20 million Americans, and cataract
surgery is the most common surgery in the US Medicare
population.4
Previous research has well established that cataract surgery improves visual acuity. In addition, substantial research has investigated the impact of cataract surgery on
self-reported quality of life. Most of this previous research
has focused on surveys or questionnaires to assess subjective quality of life. A variety of questionnaires have been
used to evaluate different aspects of quality of life, ranging
2013 by the American Academy of Ophthalmology
Published by Elsevier Inc.

from glare disability, acuity/spatial vision, depth perception,

peripheral vision, visual search, and visual processing
speed, and most have shown subjective increases in quality
of life after cataract surgery.512 One of these questionnaires, the Activities of Daily Vision Scale (ADVS), assesses the difficulty patients have in distance and near
activities as well as from glare. Multiple studies report
ADVS improvement after cataract surgery.1315 Research
focusing on first- versus second-eye surgery has often evaluated the absolute gains in visual acuity and self-reported
functioning outcomes. Several studies have reported smaller
absolute gains after second-eye surgery, given that first-eye
surgery has already led to substantial improvement. However, most studies of first- and second-eye surgery have
generally concluded that second-eye surgery is beneficial, at
least for a subset of patients.7,16 25
ISSN 0161-6420/13/$see front matter
http://dx.doi.org/10.1016/j.ophtha.2012.10.009

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Ophthalmology Volume 120, Number 5, May 2013

Despite the amount of subjective, questionnaire-based
data available, relatively few studies have tested actual
performance to evaluate the impact of cataract and cataract
surgery on functioning, quality of life, and performance of
activities of daily living. The Salisbury Eye Evaluation
(SEE) is a longitudinal, population-based study that measured not only clinical visual function and subjective quality
of life measures but also performance on multiple tasks at
different time points.26 This article reports the impact cataract surgery has on visual function, reading speed, selfreported functioning, and measured mobility and compares
unilateral versus 2-eye surgery.

Materials and Methods

Population
The SEE enrolled community-dwelling residents of Salisbury,
Maryland, who were chosen randomly from an age- and racestratified sample of residents in selected Maryland ZIP codes and
whose names were on the national Medicare eligibility list. Participants were required to be able to travel to clinic visits and to
have a Mini-Mental Status Examination (MMSE) score of 18 at
baseline. Participants were aged 65 to 84 years at the time of
enrollment. Data collection and detailed methods have been described in depth elsewhere.26,27
The analyses presented use data from the first (19931995) and
second (19951997) rounds. These 2 time points were chosen
because a standard set of performance-based measures were collected for both visits. To be included in this analysis, data from
both rounds were required. In addition, participants needed a
baseline bilateral best-corrected visual acuity (BCVA) of logarithm of the minimum angle of resolution (logMAR) 0.3 or
better (Snellen 20/40 equivalent) or to undergo cataract surgery
in at least 1 eye by round 2. Individuals with previous cataract
surgery were excluded from the primary analysis. Participants
were divided into 1 of 3 groups: individuals who did not undergo
cataract surgery during the study period, individuals who underwent cataract surgery on 1 eye between rounds 1 and 2, and
individuals who underwent surgery on both eyes between rounds 1
and 2. We did not record whether participants had a yttriumaluminum-garnet capsulotomy after cataract surgery, but this was
allowed.

Testing
Participants undertook multiple objective and subjective measures
of vision and visual functioning. They completed a 2-hour in-home
interview followed a few weeks later by an in-depth evaluation at
the clinic. All participants gave informed consent, and the procedures were approved by the Johns Hopkins University School of
Medicine Institutional Review Board.
Researchers tested binocular visual acuity using Early Treatment Diabetic Retinopathy Study charts under standardized conditions with usual correction. Contrast sensitivity was measured
monocularly as the number of correct letters using a PelliRobson
test. Better-eye contrast was used in this study because previous
work showed that the worse-seeing eye had a negligible contribution for contrast sensitivity.28
The ADVS, intended for use in evaluating cataract surgery, was
the primary tool for assessing participants self-reported functioning for visually oriented tasks.27 This tool includes 5 subscales that
measure near vision, far vision, glare disability, night driving, and
day driving.

950

The functional tests were grouped into mobility and visionrelated manual tasks. As previously described, the timed mobility
measures involved a 4-m walk, stair ascent, stair descent, and
get-up-and-go (getting up from a chair with arms and stepping
away from it).28 Each of these performance measures was then
converted into a z score so that changes in the different performance-based mobility measures were on a comparable scale. The
z scores were calculated by subtracting the baseline mean score for
the entire study population from the individuals score and then
dividing the difference by the standard deviation of the study
population. At follow-up, z scores were calculated using the individuals score at follow-up and the baseline population mean and
standard deviation. A higher z score indicates better performance,
and a score of zero represents the mean value for the entire study
population at baseline.
Vision-related testing took place in the clinic with standardized
conditions, including lighting between 400 and 600 lux. Participants read standardized texts aloud for 15 seconds each at 4
different letter sizes (0.13, 0.21, 0.33, and 0.52 degrees) at a
distance of 1 m using customary distance glasses. The texts were
at a sixth-grade reading level, and illiterate patients were excluded
from this test.29
The comorbidity index was calculated by summing the number
of diagnoses that a doctor had given the patient from the following
list: arthritis, broken hip, back problem, heart attack, angina,
congestive heart failure, intermittent claudication, hypertension,
diabetes, emphysema, asthma after age 50 years, stroke, Parkinsons disease, vertigo, and cancer. Data on years of education,
MMSE, and depression also were collected.
The mean change for each of the values was calculated, and
differences across groups were compared using analysis of variance. Linear regression models were used to evaluate the association between each outcome of interest and surgery group after
controlling for baseline level of the outcome of interest, sex, age,
race, education, comorbidity, MMSE, and depression. The relationship between baseline mobility measurements and change in
mobility was not linear, so a spline term for the baseline mobility
score was included in the regression models evaluating mobility
measurements.
A secondary analysis was conducted of SEE participants who
had undergone 1- or 2-eye cataract surgery before baseline. Those
who had prior unilateral surgery were divided into those who
underwent second-eye surgery during the study period and those
who did not. Identical visual and mobility-related tasks were
assessed for these participants, offering longer postoperative follow-up and the opportunity to examine functionality in the time
period between first- and second-eye surgery for a portion of this
group.

Results
A total of 1739 SEE participants without prior cataract surgery met
the inclusion criteria and completed the testing at both selected
time points. Approximately 7% of participants (n 119) underwent cataract surgery on 1 or both eyes between the first 2 visits
(Table 1). Participants who underwent unilateral surgery during
the study period were significantly older than participants who did
not undergo surgery (P0.001). Slightly more than 50% of participants in each group were women, with the exception of the
bilateral cataract surgery group, in which 69% were women. The
majority of participants were Caucasian.

Lee et al One- and Two-Eye Cataract Surgery

Table 1. Baseline Characteristics of Participants without Prior Cataract Surgery Grouped by
Operative Status at Round 2 (2 Years)
Surgical Status by Round 2
No Cataract
Surgery
No.
Demographics
Age (median yrs)
Women (%)
Caucasian (%)
Education (yrs)
Health status measures
MMSE
No. of comorbidities
Depression (%)
Vision measures
Binocular BCVA (logMAR)
Contrast sensitivity (letters)
Reading speed (wpm)
Mobility and perceived function measures
ADVS
Overall mobility z score
Walking speed z score
Get up and go z score
Going up stairs z score
Going down stairs z score
Average z score for up and down stairs

1620

Unilateral Cataract
Surgery

Bilateral Cataract
Surgery

90

29

71.6
57
72
11.4

76.1*
52
81
10.6

73.0
69
72
11.9

27.4
2.3
4.1

27.1
2.4
7.1

27.0
2.7
3.7

0.04
35.7
170

0.11*
32.9*
131*

0.22*
31.6*
109*

91.9
0.09
0.12
0.12
0.08
0.11
0.10

84.9*
0.22*
0.20*
0.15*
0.24*
0.25*
0.24*

80.2*
0.29
0.22
0.13
0.29
0.38*
0.28

ADVS Activities of Daily Vision Scale; BCVA best-corrected visual acuity; logMAR logarithm of the
minimum angle of resolution; MMSE Mini-Mental Status Examination; wpm words per minute.
All values shown are means. The BCVA was measured with both eyes together and is shown in logMAR. Contrast
sensitivity is the number of correct letters in the better-seeing eye with correction on a PelliRobson chart. The
0.21-degree text, the size of newspaper print, was used for the reading speed. The z score is the difference between
the measured time and the baseline mean time for the entire study population divided by the baseline standard
deviation, so a positive z score denotes better performance.
*Statistically significant difference compared with no cataract surgery group (P0.05).

Reading speed was not tested in 95 participants in the no surgery group, 4 participants in the unilateral group, and
2 participants in the bilateral group.

Baseline Vision and Physical Functioning

Measures
As expected, at baseline the group without subsequent cataract
surgery had significantly better binocular BCVA, contrast sensitivity, reading speed, and ADVS than the groups that subsequently
had surgery. The unilateral group had significantly worse mobility,
both overall and on all subscales, than the no surgery group, which
had z scores above the study population mean (Table 1).

Change in Vision and Subjective Measures by

Round 2
Comparing baseline and 2-year follow-up data for the no surgery
group provided the opportunity to evaluate the natural decline associated with aging, thus establishing the context for evaluating changes
associated with surgery. Although the no surgery group experienced
a decline in bilateral BCVA of 0.05 logMAR by the 2-year follow-up,
both the unilateral and bilateral surgery groups had statistically significant improvements (0.02 and 0.17 logMAR improvement, respectively; Table 2). By adjusting for baseline values, both surgery groups
had significantly better change in contrast sensitivity than the no
surgery group, with a small decline in the unilateral surgery group and
a 1.3-letter improvement in the bilateral surgery group. Likewise,
change in reading speed was significantly better for both surgery

groups, with less decrease for the unilateral group than the no surgery
group (4.9 vs. 26.7 words; P 0.006) and substantial improvement for the bilateral group (28 words per minute [wpm] improvement; P0.0001), bringing overall average 2-year values to 144 wpm
for the no surgery group, 129 wpm for unilateral surgery, and 140
wpm for bilateral surgery.
The ADVS was essentially unchanged for the unoperated group,
whereas the unilateral group showed an insignificant small decline,
and the bilateral group showed significant improvement (Table 2).
The bilateral surgery group also showed a significant improvement
compared with the unilateral surgery group (P 0.003).

Change in Mobility by Round 2

At round 2, mean mobility z scores declined for both the no
surgery and unilateral surgery groups and were essentially unchanged for the bilateral surgery group. The unilateral surgery
group, which was the oldest on average, had a significant decrease
in mobility, even after adjusting for age and baseline score. The
bilateral group showed a trend toward less mobility decline than
either of the other 2 groups and improvement in all individual
mobility tasks in addition to get up and go; however, likely
because of sample size, these differences were not statistically
significant (Table 3).

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Ophthalmology Volume 120, Number 5, May 2013

Table 2. Change in Visual Performance, Reading Speed, and
Subjective Evaluation of Performance on Daily Tasks

Table 4. Multivariate Analyses Evaluating Change in Each

Measure Compared with the No Surgery Group for Previously
Unoperated Participants*

Surgical Status by Round 2

Parameter
Visual acuity improvement
(logMAR)
Contrast sensitivity
(letters)
Reading speed (wpm)
ADVS

No Cataract
Surgery
0.05

Unilateral
Surgery
0.02*

0.17*

1.6

0.48*

1.3*

26.7
0.14

4.9*
2.0

28.2*
9.0*

ADVS Activities of Daily Vision Scale; logMAR logarithm of the

minimum angle of resolution; wpm words per minute.
For all measurements, a positive change denotes improvement. The
BCVA was measured with both eyes together and is shown as improvement in logMAR. Contrast sensitivity is the number of correct letters in
the better-seeing eye with best correction on a PelliRobson chart. The
0.21-degree text, the size of newspaper print, was used for the reading
speed.
*Statistically significant (P0.05) difference comparing that group with
no cataract surgery, adjusting for baseline value.

Regression Models
Multivariate linear regression models showed the unilateral and
bilateral groups to have a statistically significant improvement in
BCVA compared with the no surgery group, with the bilateral
surgery group benefiting more (0.04 vs. 0.13 logMAR improvement, Table 4), even after adjustment. Multivariate analyses comparing the unilateral versus the bilateral group also showed greater
improvement in the bilateral group (0.12-logMAR improvement;
P 0.0005). The unilateral group had a small, nonsignificant
improvement in contrast sensitivity compared with the no surgery
group (0.16 letters), whereas the bilateral surgery group had a
statistically significant improvement (0.93 letters, P 0.03) compared with the no surgery group. Reading speed significantly
improved for both the unilateral (11.6 wpm, P 0.003) and
bilateral surgery groups (31.1 wpm, P0.0001) compared with the
no surgery group.
Table 3. Mean Change in Performance on Mobility Tasks
between Baseline and Round 2 (2 Years) among Individuals
without Surgery at Baseline
Surgical Status By Round 2
Change in z Score

No Cataract
Surgery

Unilateral
Surgery

Bilateral Cataract
Surgery

Overall mobility score*

Walking speed
Get up and go speed
Going up stairs speed
Going down stairs speed
Average stair speed

0.13
0.09
0.21
0.10
0.03
0.07

0.32
0.26
0.42
0.33
0.30
0.34

0.02
0.13
0.21
0.09
0.04
0.18

The z score is the difference between the measured speed to perform the
task and the baseline mean speed for the entire study population divided
by the baseline standard deviation. So, a positive z score denotes better
performance than the average.
*Calculated by averaging the z scores for all mobility-related tasks.

P0.05 for all values compared with no surgery group, with P value
adjusted for baseline z score.

952

Surgical Status by Round 2

Bilateral Cataract
Surgery
Change
Visual acuity (logMAR improvement)
Contrast sensitivity (letters)
Reading speed (wpm)
Mobility (z score)
Average mobility score
Walking speed
Get up and go speed
Going up stairs speed
Going down stairs speed
Overall stair speed
ADVS
Overall
Distance
Near
Glare
Day driving
Night driving

Unilateral
Surgery

Bilateral Cataract
Surgery

0.04
0.16
11.6

0.13
0.93
31.1

0.18
0.18
0.19
0.24
0.26
0.27

0.18
0.15
0.01
0.22
0.08
0.28

5.0
4.8
4.7
8.4
9.0
8.4

4.9
2.2
4.5
5.5
1.0
5.9

ADVS Activities of Daily Vision Scale; logMAR logarithm of the

minimum angle of resolution; wpm words per minute.
All values shown are the change compared with the reference group after
adjusting for the variables as discussed below. Visual acuity was measured
with best correction using both eyes together and is shown in logMAR.
Contrast sensitivity is the number of correct letters in the better-seeing eye
with correction on a PelliRobson chart. The 0.21-degree text, the size of
newspaper print, was used for the reading speed. The z score is the
difference between the measured time and the baseline mean time for the
entire study population divided by the baseline standard deviation, so a
positive z score denotes better performance.
*For each variable, the regression model controlled for sex, age, race,
education, comorbidity, Mini-Mental Status Examination, depression, and
the baseline value for the outcome being evaluated. The walking score also
included a spline term to adjust for baseline walking speed.

Statistically significant difference compared with no surgery group

(P0.05).

The unilateral surgery group had a statistically significant decrease in ADVS compared with the no surgery group, even after
adjustment for age and other potential confounders. In contrast, the
bilateral surgery group improved significantly in ADVS and
showed a consistent but not statistically significant trend toward
improved mobility on each of the mobility tasks compared with the
no surgery group (Table 4).
A subset of the unilateral surgery group (n 14) had BCVA
0.3 logMAR in the unoperated eye at baseline. This subset had
worse vision and physical functioning scores at baseline than the
rest of the unilateral surgery group. This subset had a slightly
larger improvement in BCVA after surgery than the rest of the
unilateral surgery group (0.07 logMAR) and an equal improvement in reading speed (12.2 wpm), but it had less improvement in
contrast sensitivity and larger declines in ADVS and mobility.
Thus, this subgroup may not have benefited from surgery in the
same way that participants with good contralateral vision did.
Conducting the same primary analyses described earlier after removing these participants from the unilateral surgery group does
not alter the results substantially. All interpretations remain the
same for both the analyses comparing the unilateral group with no
surgery and comparing the unilateral group with bilateral surgery.

Lee et al One- and Two-Eye Cataract Surgery

Secondary Analysis of Participants with Surgery at
Baseline
A total of 456 participants entered the SEE with prior cataract
surgery at baseline. Although 218 participants had prior surgery in
both eyes, 189 had unilateral surgery without second-eye surgery
before round 2 and 49 had second-eye surgery during the study
period. The average age was more similar across these groups than
in the primary analysis, making them well suited for comparisons
that may be influenced by age. Secondary analyses showed that the
group with second-eye surgery between rounds 1 and 2 had the
greatest improvement in BCVA and ADVS and the least decline in
contrast sensitivity, reading speed, and mobility (data not shown),
confirming the findings from the primary analyses.

Discussion
The results of this study demonstrate an objectively measureable benefit of cataract surgery on visual performance, reading
speed, and relative mobility. This study also confirms the
subjective benefit that patients undergoing cataract surgery
may experience as measured by the ADVS, verifying previously published work.1315 Results also suggest that participants who undergo second-eye surgery are likely to function
better than those who undergo only unilateral surgery. The fact
that the SEE is a population-based study gives particular
strength to the conclusions drawn in comparison with the
previously published work on cataract surgery outcomes; however, the number of patients undergoing cataract surgery was
only a small percentage of the study population. Further evaluation is needed in a larger population.
The baseline values agree with prior reports demonstrating
the significant deleterious impact that cataract has on performance of everyday activities. The round 2 results showed
objectively measureable performance benefits from cataract
surgery, but the impact differed depending on whether participants had 1- or 2-eye surgery. Those who had bilateral cataract
surgery performed better and had larger increases in BCVA,
contrast sensitivity, and reading speed in the multivariate analysis (Table 4). Furthermore, the bilateral group had better
mobility and ADVS at follow-up, whereas the unilateral surgery group had significant declines in both. Thus, at follow-up,
the bilateral surgery group had higher overall mobility and
ADVS scores than the unilateral surgery group.
This finding supports the conclusion that second-eye
cataract surgery provided a significant additional benefit to
first-eye cataract surgery in this community-based study, in
which participants underwent cataract surgery during the
course of their normal eye care. One relevant limitation of
the study is that follow-up visits are time-specific and not
intervention-based, so separating out the incremental benefit
of operating on the first eye and second eye is difficult.
However, the secondary analysis helps in this regard. The
group with unilateral surgery at baseline that had secondeye surgery by round 2 outperformed its peers who did not
have second eye surgery in all tested measures. A future
study could perform a comprehensive assessment of physical functioning before first-eye surgery, between eyes, and
after surgery in the second eye to answer this more directly.
This study makes a new contribution to the literature
because previous work on second-eye surgery has not re-

ported this type of performance-based, measureable, functional benefit. Other researchers have shown that patients
undergoing bilateral cataract surgery have greater subjective satisfaction along with clinical improvement in acuity and stereopsis than those undergoing unilateral surgery.7,16,17,2325 Moreover, those who undergo second-eye
surgery have a higher likelihood of meeting the drivers
license field of vision requirement,30 and 1 study showed a
nonsignificant trend toward fewer falls among patients with
prior unilateral cataract surgery randomized to second-eye
surgery versus no surgery.24
One may argue that individuals who do not undergo second-eye surgery make this decision because their second eye
will not benefit from surgery or they have attained sufficient
satisfaction from first-eye surgery. However, our subgroup
analysis that removes patients who underwent unilateral surgery with poor vision in the contralateral eye shows that even
among those who have good vision in the fellow eye, those
who underwent unilateral surgery do not perform as well at
follow-up as those who underwent second-eye surgery.
Studies that have investigated differences between firstand second-eye cataract surgery have generally reported
greater absolute improvements in bilateral acuity and selfreported quality of life after first-eye surgery. However,
these studies have generally shown a benefit from secondeye surgery as well. In most cases, individuals undergoing
second-eye surgery have already experienced large gains
associated with first-eye surgery, and improvement after
second-eye surgery is limited by the upper limit of measuring full function. For example, on the ADVS, the maximum
score is 100; thus, individuals who begin closer to 100 (e.g.,
those who have already undergone first-eye surgery) have
less opportunity for large absolute improvements than individuals starting further away from 100 (e.g., those undergoing first-eye surgery). Therefore, when making such comparisons, it is important to evaluate the final level of
function, not just the amount of change.
Although individuals undergoing second-eye surgery
may have a smaller absolute increase in a particular outcome, that increase may be equally or more important than
the initial increase, such as reaching a level of visual acuity
that allows a person to drive again. In this study, we evaluated individuals before surgery and then after 1- or 2-eye
surgery. Thus, the 2-eye surgery group is not directly comparable to the second-eye surgery groups from previous
studies. Instead, it is more likely to show the combined
effects of first- and second-eye surgery. Our finding is
consistent with a previous clinical trial in which patients
undergoing 2-eye surgery had better acuity, stereopsis, and
14-item Visual Function score than patients with bilateral
cataracts undergoing 1-eye surgery.7
Future research should continue to explore ways to understand the impact of cataract surgery on quality of life.
For instance, the mobility z scores in all groups decreased
from round 1 to 2, suggesting the importance of many
aspects of aging in addition to visual impairment. However,
many of these aging-related factors, such as cardiovascular
disease, neurologic disease, or joint disease, are more difficult to treat than cataract, which requires a relatively brief
episodic intervention. As the elderly population increases,

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cataract surgery may allow more patients to live independently longer and more safely.
Given the greater benefit observed in patients who underwent bilateral cataract surgery, providers should closely
follow patients who may benefit from surgery. This includes
carefully asking patients who have already undergone unilateral cataract surgery if they are experiencing continued
difficulty with contrast sensitivity, reading, mobility, or
other visual needs, even if their visual acuity seems to be
satisfactory. When treating a patient with diminished visual
function, providers should not assume that operating on
only 1 eye has restored maximum function, even if the
outcome of the first surgery was excellent.
In conclusion, cataract is a widespread eye disease, and
cataract surgery is a commonly performed surgery. Because of
the significant Medicare expenditures on cataract surgery, it
will come under scrutiny as health care costs continue to
increase. The health reform legislation passed in 2010 establishes a Patient-Centered Outcomes Research Institute at the
national level, and states are also implementing measures in an
effort to pay for only evidence-based medicine.31,32 This article demonstrates in a large, population-based prospective study
not only that cataract surgery provides functional benefit but
also that bilateral cataract surgery seems to benefit patients in
ways that unilateral surgery does not.

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Lee et al One- and Two-Eye Cataract Surgery

Footnotes and Financial Disclosures

Originally received: December 10, 2011.
Final revision: October 2, 2012.
Accepted: October 3, 2012.
Available online: January 26, 2013.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials
discussed in this article.
Manuscript no. 2011-1766.

Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore,

Maryland.

Department of Ophthalmology, University of Washington, Seattle, Washington.

Public Health Sciences, Wake Forest School of Medicine, WinstonSalem, North Carolina.

This study was funded by Grant AG10184 from the National Aging
Institute. Dr. Gower is the recipient of an Ernest and Elizabeth Althouse
Special Scholars Award from Research to Prevent Blindness (RPB). Dr.
West is the recipient of a Senior Scientific Investigator Award from RPB.
Correspondence:
Emily W. Gower, PhD, Wake Forest Health Sciences, Medical Center
Blvd., Winston-Salem, NC 27157. E-mail: egower@wakehealth.edu.

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